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Stella F, Radanovic M, Gallucci-Neto J, Forlenza OV. Electroconvulsive therapy for treating patients with agitation and related behavioral disorders due to dementia: a systematic review. Dement Neuropsychol 2023; 17:e20230007. [PMID: 37533598 PMCID: PMC10392879 DOI: 10.1590/1980-5764-dn-2023-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/08/2023] [Accepted: 04/12/2023] [Indexed: 08/04/2023] Open
Abstract
Behavioral disturbances are clinically relevant in patients with dementia, and pharmacological regimens to mitigate these symptoms have provided limited results. Proven to be effective in several psychiatric conditions, electroconvulsive therapy is a potentially beneficial strategy for treating severe agitation due to dementia. Objective This review aimed to examine the publications on the efficacy, safety and tolerability of electroconvulsive therapy in treating patients with agitation due to dementia. Methods We performed a systematic analysis on the electroconvulsive therapy to treat patients with dementia and coexisting severe agitation. Articles were classified according to the level of evidence based on methodological design. Patients received an acute course of electroconvulsive therapy, often followed by maintenance intervention. Results We selected 19 studies (156 patients; 64.1% women; 51-98 years old), which met the inclusion criteria: one case-control study by chart analysis (level of evidence 2); one open-label study (level of evidence 3); three historical/retrospective chart analyses (level of evidence 4); and 14 case series/reports (level of evidence 5). No randomized, sham-controlled clinical trials (level of evidence 1) were identified, which represents the main methodological weakness. Some patients had postictal delirium, cardiovascular decompensation and cognitive changes, lasting for a short time. Conclusions Overall, patients achieved significant improvement in agitation. However, the main finding of the present review was the absence of methodological design based on randomized and sham-controlled clinical trials. Despite methodological limitations and side effects requiring attention, electroconvulsive therapy was considered a safe and effective treatment of patients with severe agitation and related behavioral disorders due to dementia.
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Affiliation(s)
- Florindo Stella
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Psiquiatria, LIM-27, São Paulo SP, Brazil
- Universidade Estadual Paulista, Instituto de Biociências, Rio Claro SP, Brazil
| | - Márcia Radanovic
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Psiquiatria, LIM-27, São Paulo SP, Brazil
| | - José Gallucci-Neto
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Psiquiatria, Serviço de ECT, São Paulo SP, Brazil
| | - Orestes Vicente Forlenza
- Universidade de São Paulo, Faculdade de Medicina, Instituto de Psiquiatria, LIM-27, São Paulo SP, Brazil
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McManus KR, Lapid MI, Forester BP, Mueller M, Hermida AP, Nykamp L, Harper DG, Seiner SJ, Sanghani S, Patrick R, Gentry MT, Kung S, Leal JC, Johnson EK, Petrides G. Simulated Electroconvulsive Therapy: A Novel Approach to a Control Group in Clinical Trials. J ECT 2022; 38:165-170. [PMID: 35220356 PMCID: PMC9420159 DOI: 10.1097/yct.0000000000000832] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Agitation is the most common behavioral symptom of Alzheimer disease (AD) affecting approximately 40% to 60% of the AD population, yet there are no Food and Drug Administration-approved therapies for the myriad of behavioral or psychological symptoms of dementia. There is growing evidence from naturalistic studies that electroconvulsive therapy (ECT) is a safe and effective treatment for agitation in AD patients who are refractory to pharmacotherapy and behavioral interventions. Despite the existing evidence, ECT remains underused because of stigma, lack of education, and concerns regarding adverse cognitive effects. Randomized controlled clinical trials of ECT are an opportunity to provide high-quality evidence of ECT as a safe and efficacious treatment for agitation in the AD population. We describe the methods for the Electroconvulsive Therapy in Alzheimer's Dementia study, which uses a novel, simulated ECT (S-ECT) control group to conduct a single-blind efficacy study of ECT for the treatment of agitation and aggression in individuals with moderate to severe AD. METHODS We discuss the rationale, study design, methodology, ethical and practical challenges, and management strategies in using an S-ECT group as the comparator arm in this randomized controlled trial of ECT in AD-related treatment refractory agitation and aggression. CONCLUSIONS Validation of the safety and efficacy of ECT in patients with advanced AD with refractory agitation and aggression is necessary. This can be accomplished through creative formulation of S-ECT groups that effectively maintain the blind while providing scientific integrity.
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Affiliation(s)
| | | | - Brent P. Forester
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA
- Harvard Medical School, Boston, MA
| | | | | | - Louis Nykamp
- Pine Rest Christian Mental Health Services, Grand Rapids, MI
| | - David G. Harper
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA
- Harvard Medical School, Boston, MA
| | - Stephen J. Seiner
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA
- Harvard Medical School, Boston, MA
| | - Sohag Sanghani
- The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Regan Patrick
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA
- Harvard Medical School, Boston, MA
| | | | | | | | | | - Georgios Petrides
- The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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Chan P, Waxman RE, Woo S, Docherty C, Rayani K, Fischler I, Ghaffar O, Elmi S. Electroconvulsive Therapy for Neuropsychiatric Symptoms due to Major Neurocognitive Disorder: A Prospective, Observational Study. J ECT 2022; 38:81-87. [PMID: 35613007 DOI: 10.1097/yct.0000000000000814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Neuropsychiatric symptoms (NPSs) in those with major neurocognitive disorder (MNCD) include the responsive behaviors of agitation and aggression. Electroconvulsive therapy (ECT) has shown some effectiveness based on retrospective studies and one open label prospective study. We hypothesized that ECT will reduce NPSs between baseline and after treatment in those with medication-refractory behaviors. METHOD/DESIGN This Canadian prospective multicenter study included MNCD patients admitted to geriatric psychiatry units for the management of refractory NPSs. All treatment-refractory participants suffered from advanced MNCD. We conducted the Neuropsychiatric Inventory-Clinician version and the Pittsburgh Agitation Scale at baseline, and during and after the ECT course. A bitemporal or bifrontal ECT series based on dose titration to 1.5 to 2.5 times seizure threshold was administered. RESULTS Data were collected for 33 patients with a mean age of 73 and categorized with severe MNCD using the Functional Assessment Staging of Alzheimer's Disease scale (stages 6 and 7). The data showed a drop in mean Neuropsychiatric Inventory-Clinician version from 58.36 to 24.58 (P < 0.0001). Mean Neuropsychiatric Inventory agitation subscale dropped from 7.12 to 3.09 (P = 0.007). Mean Neuropsychiatric Inventory aggression subscale dropped from 6.94 to 0.97 (P < 0.0001). There was a concomitant significant decline in Pittsburgh Agitation Scale scores. No participants dropped out because of intolerance of ECT. One participant died from pneumonia, which did not appear related to ECT. CONCLUSIONS In this naturalistic study, ECT was found to be a safe and effective treatment for certain NPSs in people with MNCD. This can translate into improving quality of life.
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Affiliation(s)
| | | | | | - Claire Docherty
- From the Department of Psychiatry, Faculty of Medicine, University of British Columbia
| | - Kaveh Rayani
- Undergraduate Program, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
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Hermida AP, Tang YL, Glass O, Janjua AU, McDonald WM. Efficacy and Safety of ECT for Behavioral and Psychological Symptoms of Dementia (BPSD): A Retrospective Chart Review. Am J Geriatr Psychiatry 2020; 28:157-163. [PMID: 31668364 DOI: 10.1016/j.jagp.2019.09.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/21/2019] [Accepted: 09/23/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Much of the functional disturbance in patients with dementia reflects the presence of noncognitive behavioral and psychological symptoms of dementia (BPSD). Agitation is among the most distressing symptoms for patients, clinicians, and caregivers. Currently no pharmacotherapy has clearly been shown to be of value for this condition. This study used a chart review method to examine the safety and efficacy of electroconvulsive therapy (ECT) for patients with dementia receiving ECT for agitation. METHODS A retrospective chart review was conducted of patients with dementia presenting with symptoms of aggression or agitation and who received ECT treatments. Aggression and agitation were measured by pre- and post-ECT Pittsburg Agitation Scale (PAS) scores. Detailed history of the use of psychotropic medications as well as other clinically relevant variables was analyzed. FINDINGS Sixty elderly patients (45 women and 15 men, 75% female, mean age 77.5 ± 8.0 years) were included in the analysis. Most patients were treatment resistant to multiple psychotropic medications prior to ECT (mean number 6.1±1.5). The baseline PAS total was 9.3 ± 3.7 and it decreased significantly after three (2.5±2.8) and six (1.5±2.3) ECT treatments. No significant ECT-related medical complications were observed except transient confusion. A decrease in the number of psychotropics prescribed along with an increase in the GAF score was observed after the ECT treatment course. CONCLUSION ECT was safe in this sample of patients who had co-morbid medical conditions. ECT was associated with the following observations: 1) a reduction in agitation; 2) a reduction in psychotropic polypharmacy; and 3) an improvement in global functioning level. Further research evaluating the effects of ECT in the setting of dementia is warranted.
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Affiliation(s)
- Adriana P Hermida
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA.
| | - Yi-Lang Tang
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Oliver Glass
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - A Umair Janjua
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - William M McDonald
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
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Camilleri JA, Hoffstaedter F, Zavorotny M, Zöllner R, Wolf RC, Thomann P, Redlich R, Opel N, Dannlowski U, Grözinger M, Demirakca T, Sartorius A, Eickhoff SB, Nickl-Jockschat T. Electroconvulsive therapy modulates grey matter increase in a hub of an affect processing network. NEUROIMAGE-CLINICAL 2019; 25:102114. [PMID: 31884221 PMCID: PMC6939059 DOI: 10.1016/j.nicl.2019.102114] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 11/21/2019] [Accepted: 12/02/2019] [Indexed: 02/09/2023]
Abstract
We here present a structural neuroimaging study reporting on a large multi-site patient sample with unipolar depression that underwent ECT. Patients showed grey matter increases in the medial temporal lobe. Connectivity modeling revealed that this altered brain region was involved in networks related to affect processing and memory. This provides a potential explanation, how these structural changes during ECT are involved in both main and side effects of the treatment.
A growing number of recent studies has suggested that the neuroplastic effects of electroconvulsive therapy (ECT) might be prominent enough to be detected through changes of regional gray matter volumes (GMV) during the course of the treatment. Given that ECT patients are difficult to recruit for imaging studies, most publications, however, report only on small samples. Addressing this challenge, we here report results of a structural imaging study on ECT patients that pooled patients from five German sites. Whole-brain voxel-based morphometry (VBM) analysis was performed to detect structural differences in 85 patients with unipolar depression before and after ECT, when compared to 86 healthy controls. Both task-independent and task-dependent physiological whole-brain functional connectivity patterns of these regions were modeled using additional data from healthy subjects. All emerging regions were additionally functionally characterized using the BrainMap database. Our VBM analysis detected a significant increase of GMV in the right hippocampus/amygdala region in patients after ECT compared to healthy controls. In healthy subjects this region was found to be enrolled in a network associated with emotional processing and memory. A region in the left fusiform gyrus was additionally found to have higher GMV in controls when compared with patients at baseline. This region showed minor changes after ECT. Our data points to a GMV increase in patients post ECT in regions that seem to constitute a hub of an emotion processing network. This appears as a plausible antidepressant mechanism and could explain the efficacy of ECT not only in the treatment of unipolar depression, but also of affective symptoms across heterogeneous disorders.
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Affiliation(s)
- Julia A Camilleri
- Institute of Neuroscience and Medicine-7, Juelich Research Center, Juelich, Germany; Institute of Systems Neuroscience, Heinrich Heine University, Duesseldorf, Germany
| | - Felix Hoffstaedter
- Institute of Neuroscience and Medicine-7, Juelich Research Center, Juelich, Germany; Institute of Systems Neuroscience, Heinrich Heine University, Duesseldorf, Germany
| | - Maxim Zavorotny
- Department of Psychiatry and Psychotherapy, Marburg Center for Mind, Brain and Behavior - MCMBB, Philipps-University Marburg, 35043 Marburg, Germany
| | - Rebecca Zöllner
- Department of Psychiatry and Psychotherapy, Marburg Center for Mind, Brain and Behavior - MCMBB, Philipps-University Marburg, 35043 Marburg, Germany
| | - Robert Christian Wolf
- Center for Psychosocial Medicine, Department of General Psychiatry, Heidelberg University, Heidelberg, Germany; Center for Mental Health, Odenwald District Healthcare Center, Erbach, Germany
| | - Philipp Thomann
- Center for Psychosocial Medicine, Department of General Psychiatry, Heidelberg University, Heidelberg, Germany
| | - Ronny Redlich
- Department of Psychiatry and Psychotherapy, University of Muenster, Muenster, Germany
| | - Nils Opel
- Department of Psychiatry and Psychotherapy, University of Muenster, Muenster, Germany
| | - Udo Dannlowski
- Department of Psychiatry and Psychotherapy, University of Muenster, Muenster, Germany
| | - Michael Grözinger
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany
| | | | | | - Simon B Eickhoff
- Institute of Neuroscience and Medicine-7, Juelich Research Center, Juelich, Germany; Institute of Systems Neuroscience, Heinrich Heine University, Duesseldorf, Germany
| | - Thomas Nickl-Jockschat
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany; Department of Psychiatry, Carver College of Medicine, University of Iowa, Iowa City, USA; Iowa Neuroscience Institute, University of Iowa, Iowa City, USA.
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Tampi RR, Tampi DJ, Young J, Hoq R, Resnick K. The place for electroconvulsive therapy in the management of behavioral and psychological symptoms of dementia. Neurodegener Dis Manag 2019; 9:283-288. [PMID: 31701804 DOI: 10.2217/nmt-2019-0018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Rajesh R Tampi
- Department of Psychiatry & Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH 44307, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA
| | | | - Juan Young
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06510, USA
| | - Rakin Hoq
- Summa Health Systems/NEOMED Psychiatry Residency Program, Akron, OH 44304, USA
| | - Kyle Resnick
- Summa Health Systems/NEOMED Psychiatry Residency Program, Akron, OH 44304, USA
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Davies SJC, Burhan AM, Kim D, Gerretsen P, Graff-Guerrero A, Woo VL, Kumar S, Colman S, Pollock BG, Mulsant BH, Rajji TK. Sequential drug treatment algorithm for agitation and aggression in Alzheimer's and mixed dementia. J Psychopharmacol 2018; 32:509-523. [PMID: 29338602 PMCID: PMC5944080 DOI: 10.1177/0269881117744996] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Behavioural and psychological symptoms of dementia (BPSD) include agitation and aggression in people with dementia. BPSD is common on inpatient psychogeriatric units and may prevent individuals from living at home or in residential/nursing home settings. Several drugs and non-pharmacological treatments have been shown to be effective in reducing behavioural and psychological symptoms of dementia. Algorithmic treatment may address the challenge of synthesizing this evidence-based knowledge. METHODS A multidisciplinary team created evidence-based algorithms for the treatment of behavioural and psychological symptoms of dementia. We present drug treatment algorithms for agitation and aggression associated with Alzheimer's and mixed Alzheimer's/vascular dementia. Drugs were appraised by psychiatrists based on strength of evidence of efficacy, time to onset of clinical effect, tolerability, ease of use, and efficacy for indications other than behavioural and psychological symptoms of dementia. RESULTS After baseline assessment and discontinuation of potentially exacerbating medications, sequential trials are recommended with risperidone, aripiprazole or quetiapine, carbamazepine, citalopram, gabapentin, and prazosin. Titration schedules are proposed, with adjustments for frailty. Additional guidance is given on use of electroconvulsive therapy, optimization of existing cholinesterase inhibitors/memantine, and use of pro re nata medications. CONCLUSION This algorithm-based approach for drug treatment of agitation/aggression in Alzheimer's/mixed dementia has been implemented in several Canadian Hospital Inpatient Units. Impact should be assessed in future research.
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Affiliation(s)
- Simon JC Davies
- Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, ON, Canada
- Dementia Integrated Pathway Working Group, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Amer M Burhan
- Dementia Integrated Pathway Working Group, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Geriatric Psychiatry, Western University, London, ON, Canada
| | - Donna Kim
- Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, ON, Canada
- Dementia Integrated Pathway Working Group, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Philip Gerretsen
- Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, ON, Canada
- Dementia Integrated Pathway Working Group, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Multimodal Imaging Group, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Ariel Graff-Guerrero
- Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, ON, Canada
- Dementia Integrated Pathway Working Group, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Multimodal Imaging Group, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Vincent L Woo
- Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, ON, Canada
- Dementia Integrated Pathway Working Group, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Sanjeev Kumar
- Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, ON, Canada
- Dementia Integrated Pathway Working Group, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Sarah Colman
- Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, ON, Canada
- Dementia Integrated Pathway Working Group, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Bruce G Pollock
- Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, ON, Canada
- Dementia Integrated Pathway Working Group, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Benoit H Mulsant
- Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, ON, Canada
- Dementia Integrated Pathway Working Group, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Tarek K Rajji
- Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, ON, Canada
- Dementia Integrated Pathway Working Group, Centre for Addiction and Mental Health, Toronto, ON, Canada
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van den Berg JF, Kruithof HC, Kok RM, Verwijk E, Spaans HP. Electroconvulsive Therapy for Agitation and Aggression in Dementia: A Systematic Review. Am J Geriatr Psychiatry 2018; 26:419-434. [PMID: 29107460 DOI: 10.1016/j.jagp.2017.09.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 09/15/2017] [Accepted: 09/20/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Many patients with dementia develop agitation or aggression in the course of their disease. In some severe cases, behavioral, environmental, and pharmacological interventions are not sufficient to alleviate these potentially life-threatening symptoms. It has been suggested that in those cases, electroconvulsive therapy (ECT) could be an option. This review summarizes the scientific literature on ECT for agitation and aggression in dementia. METHODS We performed a systematic review in accordance with PRISMA guidelines. A search was conducted in Ovid MEDLINE, EMBASE, and PsycINFO. Two reviewers extracted the following data from the retrieved articles: number of patients and their age, gender, diagnoses, types of problem behavior, treatments tried before ECT, specifications of the ECT treatment, use of rating scales, treatment results, follow-up data, and adverse effects. RESULTS The initial search yielded 264 articles, 17 of which fulfilled the inclusion criteria. Of these studies, one was a prospective cohort study, one was a case-control study, and the others were retrospective chart reviews, case series, or case reports. Clinically significant improvement was observed in the majority (88%) of the 122 patients described, often early in the treatment course. Adverse effects were most commonly mild, transient, or not reported. CONCLUSIONS The reviewed articles suggest that ECT could be an effective treatment for severe and treatment-refractory agitation and aggression in dementia, with few adverse consequences. Nevertheless, because of the substantial risk of selection bias, the designs of the studies reviewed, and their small number, further prospective studies are needed to substantiate these preliminary positive results.
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Affiliation(s)
- Julia F van den Berg
- Parnassia Psychiatric Institute, The Hague, The Netherlands; Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | | | - Rob M Kok
- Parnassia Psychiatric Institute, The Hague, The Netherlands
| | - Esmée Verwijk
- Parnassia Psychiatric Institute, The Hague, The Netherlands; Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands; Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Selvadurai MI, Waxman R, Ghaffar O, Fischler I. Efficacy and safety of maintenance electroconvulsive therapy for sustaining resolution of severe aggression in a major neurocognitive disorder. BMJ Case Rep 2018; 2018:bcr-2017-222100. [PMID: 29305363 PMCID: PMC5775786 DOI: 10.1136/bcr-2017-222100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2017] [Indexed: 11/30/2022] Open
Abstract
We report a novel electroconvulsive therapy (ECT) regimen for sustaining the resolution of behavioural and psychological symptoms of dementia (BPSD) using alternating acute and maintenance ECT (M-ECT) trials. A 64-year-old man presenting with major neurocognitive disorder was admitted for acute behavioural disturbances and physical aggression. With few treatment options, the impact on patients' quality of life often supersedes cognitive symptoms and is a predictor of long-term institutionalisation. Recent studies indicate that ECT may be an effective and safe way to address BPSD. Clinicians have little information about when and how to stop a successful course of acute ECT or the long-term advantages of M-ECT with subsequent intermittent acute ECT. This case emphasises the benefit of M-ECT and describes potential challenges associated with abrupt discontinuation. This case is the first to detail tapering ECT for treatment of aggression in dementia by interchanging acute and M-ECT courses in response to symptom burden.
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Affiliation(s)
- Melanie Isabella Selvadurai
- DeGroote School of Business, McMaster University, Burlington, Ontario, Canada
- Department of Psychiatry, Ontario Shores Centre for Mental Health Sciences, University of Toronto, Whitby, Ontario, Canada
| | - Robyn Waxman
- Department of Psychiatry, Ontario Shores Centre for Mental Health Sciences, University of Toronto, Whitby, Ontario, Canada
| | - Omar Ghaffar
- Department of Psychiatry, Ontario Shores Centre for Mental Health Sciences, University of Toronto, Whitby, Ontario, Canada
| | - Ilan Fischler
- Department of Psychiatry, Ontario Shores Centre for Mental Health Sciences, University of Toronto, Whitby, Ontario, Canada
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Abstract
OBJECTIVES This naturalistic prospective observation study examines the efficacy of electroconvulsive therapy (ECT) in treating dementia-related agitation. METHODS Patients with dementia-related agitation who received ECT were compared with patients with the same condition who did not receive ECT using Cohen-Mansfield Agitation Inventory (CMAI), Neuropsychiatric Inventory (NPI)-nursing home version, and Clinical Global Impression Scale (CGI). Outcomes were compared between ECT-treated and non-ECT-treated patients. RESULTS A total of 9 patients were included in the study. Six received ECT, and 3 did not. Patients in the ECT and non-ECT-treated groups had comparable baseline scores (CMAI, P = 0.880; NPI, P = 0.814; and CGI, P = 0.445). The CMAI, NPI, and CGI scores were lower on final assessment in both groups with no statistically significant difference (CMAI, P = 0.771; NPI, P = 0.243; and CGI, P = 0.519). CONCLUSIONS Electroconvulsive therapy should be considered as a treatment option in the management of severe treatment refractory dementia-related agitation.
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11
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The Treatment of Disruptive Vocalization in Dementia (Behavioral and Psychological Symptoms of Dementia) With Electroconvulsive Therapy: A Case Series. J ECT 2017; 33:e9-e13. [PMID: 28009620 DOI: 10.1097/yct.0000000000000373] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There is emerging evidence that electroconvulsive therapy (ECT) can help with the behavioral and psychological symptoms of dementia. One of the most distressing behavioral symptoms of dementia is disruptive vocalization. Previous small case series have suggested that antidepressants and ECT can be beneficial for this distressing condition. The aim of this study was to describe the successful use of ECT in treating 5 patients with disruptive vocalization. METHODS A retrospective chart review of 5 patients with dementia of mixed etiologies was conducted comparing pretreatment and posttreatment scores on the Cohen-Mansfield Agitation Inventory. All 5 patients had unsuccessful treatments with nonpharmacological methods and pharmacotherapy including antidepressants. RESULTS After completion of a series of ECT, the mean verbal agitation score decreased from 6.8 (95% confidence interval, 6.3-7.3) to 2.3 (95% confidence interval, 1.3-3.3), with both clinical and statistical significance (P < 0.001). CONCLUSIONS Although further research is needed, these findings support considering the use of ECT for disruptive vocalization in dementia.
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12
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Electroconvulsive therapy (ECT) for treating agitation in dementia (major neurocognitive disorder) - a promising option. Int Psychogeriatr 2017; 29:717-726. [PMID: 28095946 DOI: 10.1017/s1041610216002258] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Agitation in patients with dementia increases caretaker burden, increases healthcare costs, and worsens the patient's quality of life. Antipsychotic medications, commonly used for the treatment of agitation in patients with dementia have a box warning from the FDA for elevated mortality risk. Electroconvulsive therapy (ECT) has made significant advances over the past several years, and is efficacious in treating a wide range of psychiatric conditions. We provide a systematic review of published literature regarding the efficacy of ECT for the treatment of agitation in patients with dementia (major neurocognitive disorder). METHODS We searched PubMed, Medline, Google Scholar, UptoDate, Embase, and Cochrane for literature concerning ECT for treating agitation in dementia using the title search terms "ECT agitation dementia;" "ECT aggression dementia;" "ECT Behavior and Psychological Symptoms of Dementia;" and "ECT BPSD." The term "dementia" was also interchanged with "Major Neurocognitive Disorder." No time frame restriction was placed. We attempted to include all publications that were found to ensure a comprehensive review. We found 11 papers, with a total (N) of 216 patients. RESULTS Limited to case reports, case series, retrospective chart review, retrospective case-control, and an open label prospective study, ECT has demonstrated promising results in decreasing agitation in patients with dementia. Patients who relapsed were found to benefit from maintenance ECT. CONCLUSIONS Available studies are often limited by concomitant psychotropic medications, inconsistent use of objective rating scales, short follow-up, lack of a control group, small sample sizes, and publication bias. A future randomized controlled trial will pose ethical and methodological challenges. A randomized controlled trial must carefully consider the definition of usual care as a comparison group. Well-documented prospective studies and/or additional case series with explicit selection criteria, a wide range of outcome measures, and less selection bias of the study sample that may favor treatment response, is warranted. ECT may be a promising option for the treatment of aggression and agitation in patients with severe dementia who are refractory to other treatment options, but the limitations of available studies suggest that a cautious approach to future randomized controlled trials is warranted.
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Acharya D, Harper DG, Achtyes ED, Seiner SJ, Mahdasian JA, Nykamp LJ, Adkison L, Van der Schuur White L, McClintock SM, Ujkaj M, Davidoff DA, Forester BP. Safety and utility of acute electroconvulsive therapy for agitation and aggression in dementia. Int J Geriatr Psychiatry 2015; 30:265-73. [PMID: 24838521 PMCID: PMC4524287 DOI: 10.1002/gps.4137] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 03/30/2014] [Accepted: 04/02/2014] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Agitation and aggression are among the most frequent and disruptive behavioral complications of dementia that contribute to increased cost of care, hospitalization, caregiver burden, and risk of premature institutionalization. This current study examined the safety and efficacy of electroconvulsive therapy (ECT) as a treatment for behavioral disturbances in dementia. We hypothesized that ECT would result in reduced agitated and aggressive behaviors between baseline and discharge. METHODS Twenty-three participants admitted to McLean Hospital (Belmont, MA, USA) and Pine Rest Christian Mental Health Services (Grand Rapids, MI, USA), with a diagnosis of dementia who were referred for ECT to treat agitation and/or aggression, were enrolled in the study. We administered the Cohen-Mansfield Agitation Inventory-Short Form, Neuropsychiatric Inventory-Nursing Home Version, Cornell Scale for Depression in Dementia, and the Clinical Global Impression Scale at baseline, during, and after the ECT course. RESULTS Regression analyses revealed a significant decrease from baseline to discharge on the Cohen-Mansfield Agitation Inventory (F(4,8) = 13.3; p = 0.006) and Neuropsychiatric Inventory (F(4,31) = 14.6; p < 0.001). There was no statistically significant change in scores on the Cornell Scale for Depression in Dementia. The Clinical Global Impression scores on average changed from a rating of "markedly agitated/aggressive" at baseline to "borderline agitated/aggressive" at discharge. Treatment with ECT was well tolerated by most participants; discontinuation of ECT occurred for two participants because of recurrence of agitation and for three participants because of adverse events. CONCLUSIONS Electroconvulsive therapy may be a safe treatment option to reduce symptoms of agitation and aggression in patients with dementia whose behaviors are refractory to medication management.
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Affiliation(s)
- Deepa Acharya
- Geriatric Mood Disorders Research Program, McLean Hospital, Belmont, MA; Harvard Medical School,Psychology Service, VA Boston Healthcare System, Boston, MA
| | - David G. Harper
- Geriatric Mood Disorders Research Program, McLean Hospital, Belmont, MA; Harvard Medical School
| | - Eric D. Achtyes
- Pine Rest Christian Mental Health Services, Michigan State University, Grand Rapids, MI
| | - Stephen J. Seiner
- Psychiatric Neurotherapeutics Program, McLean Hospital, Belmont, MA; Harvard Medical School
| | - Jack A. Mahdasian
- Pine Rest Christian Mental Health Services, Michigan State University, Grand Rapids, MI
| | - Louis J. Nykamp
- Pine Rest Christian Mental Health Services, Michigan State University, Grand Rapids, MI
| | | | | | - Shawn M. McClintock
- Neurocognitive Research Laboratory, Division of Brain Stimulation and Neurophysiology, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC,Department of Psychiatry, UT Southwestern Medical Center, Dallas, TX
| | - Manjola Ujkaj
- Psychiatric Neurotherapeutics Program, McLean Hospital, Belmont, MA; Harvard Medical School
| | - Donald A. Davidoff
- Department of Neuropsychology, McLean Hospital, Belmont, MA; Harvard Medical School
| | - Brent P. Forester
- Geriatric Mood Disorders Research Program, McLean Hospital, Belmont, MA; Harvard Medical School
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Liu AY, Rajji TK, Blumberger DM, Daskalakis ZJ, Mulsant BH. Brain stimulation in the treatment of late-life severe mental illness other than unipolar nonpsychotic depression. Am J Geriatr Psychiatry 2014; 22:216-40. [PMID: 23891366 PMCID: PMC3900599 DOI: 10.1016/j.jagp.2013.02.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 02/17/2013] [Accepted: 02/19/2013] [Indexed: 11/18/2022]
Abstract
Late-life mental illness is a growing concern. Current medications have limited efficacy and are associated with safety concerns. A variety of brain stimulation approaches offers alternative treatments. We performed a systematic literature search on the efficacy and safety of brain stimulation in late-life mental illnesses, excluding unipolar nonpsychotic depression. Studies on deep brain stimulation, electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and vagal nerve stimulation that enrolled exclusively older adults (≥65 years) or analyzed older adults as a separate group were included. The search identified 1,181 publications, of which 43 met the above inclusion criteria: 24 were related to the treatment of non-unipolar depression (ECT: 21; rTMS: 2; ECT and rTMS: 1), 14 related to dementia (ECT: 7[2 of these studies were also related to depression]; vagal nerve stimulation: 2; rTMS: 4; deep brain stimulation: 1), and 7 to schizophrenia (ECT: 7). These studies reported a high degree of variability in efficacy and safety with promising results in general, particularly in the treatment of dementia and schizophrenia. Most publications were limited by small sample sizes, lack of control conditions, and lack of randomization. Large studies with a randomized controlled design or other designs such as crossover or off-on-off-on are needed. In contrast to the empiric and nonspecific use of ECT, future studies using modalities other than ECT could focus on novel biologically based interventions that target specific circuitry. These interventions could also be combined with other non-brain stimulation treatments for possible synergistic effects.
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Affiliation(s)
- Angela Y Liu
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Tarek K Rajji
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
| | - Daniel M Blumberger
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Zafiris J Daskalakis
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Benoit H Mulsant
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Kerner N, Prudic J. Current electroconvulsive therapy practice and research in the geriatric population. NEUROPSYCHIATRY 2014; 4:33-54. [PMID: 24778709 PMCID: PMC4000084 DOI: 10.2217/npy.14.3] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Electroconvulsive therapy (ECT) is utilized worldwide for various severe and treatment-resistant psychiatric disorders. Research studies have shown that ECT is the most effective and rapid treatment available for elderly patients with depression, bipolar disorder and psychosis. For patients who suffer from intractable catatonia and neuroleptic malignant syndrome, ECT can be life saving. For elderly patients who cannot tolerate or respond poorly to medications and who are at a high risk for drug-induced toxicity or toxic drug interactions, ECT is the safest treatment option. Organic causes are frequently associated with late-life onset of neuropsychiatric conditions, such as parkinsonism, dementia and stroke. ECT has proven to be efficacious even when these conditions are present. During the next decade, research studies should focus on the use of ECT as a synergistic therapy, to enhance other biological and psychological treatments, and prevent symptom relapse and recurrence.
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Affiliation(s)
- Nancy Kerner
- Electroconvulsive Therapy Service & the Division of Geriatric Psychiatry, New York State Psychiatric Institute, & the College of Physicians & Surgeons of Columbia University, 1051 Riverside Drive, New York, NY 10032, USA
| | - Joan Prudic
- Electroconvulsive Therapy Service & the Division of Geriatric Psychiatry, New York State Psychiatric Institute, & the College of Physicians & Surgeons of Columbia University, 1051 Riverside Drive, New York, NY 10032, USA
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Aksay SS, Hausner L, Frölich L, Sartorius A. Severe agitation in severe early-onset Alzheimer's disease resolves with ECT. Neuropsychiatr Dis Treat 2014; 10:2147-51. [PMID: 25419138 PMCID: PMC4235491 DOI: 10.2147/ndt.s71008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Dementia-related behavioral disturbances are mostly treated with antipsychotics; however, the observed beneficial effects are modest and the risk of serious adverse effects high. We report the case of a 57-year-old woman with severe early-onset Alzheimer's disease and severe agitation, whom we treated with electroconvulsive therapy (ECT). A significant clinical improvement was achieved over eight ECT sessions, which were tolerated well without cognitive worsening, and lasted approximately 3 months. Our case demonstrates the safe and effective use of ECT in pharmacotherapy-resistant severe agitation in Alzheimer's disease. The risk-benefit profile of ECT for dementia-related agitation should be further investigated in clinical trials.
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Affiliation(s)
- Suna Su Aksay
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Lucrezia Hausner
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Lutz Frölich
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Alexander Sartorius
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Abstract
SummaryElectroconvulsive therapy (ECT) is a powerful acute treatment for severe and resistant depression. We review literature related to the efficacy, safety and tolerability of ECT in older people, with an emphasis on research studies and reviews published in the last 25 years. In general ECT has been considered a very effective and safe treatment for depression and other psychiatric and non-psychiatric disorders in older people. Amnesia is commonly attributed to ECT treatment, but studies suggest that the negative effects of ECT on cognition are probably small in older patients. Currently the balance of risks and benefits of ECT justify its use for severe depression in older patients, both with and without dementia.
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Safety and efficacy of electroconvulsive therapy for the treatment of agitation and aggression in patients with dementia. Am J Geriatr Psychiatry 2012; 20:61-72. [PMID: 22143072 DOI: 10.1097/jgp.0b013e3182051bbc] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Noncognitive behavioral disturbances including agitation and aggression frequently accompany the cognitive symptoms of dementia accounting for much of dementia's morbidity, yet treatment options are currently limited. The authors examine the safety and efficacy of Electroconvulsive Therapy (ECT) for agitation and aggression in dementia patients. DESIGN Retrospective systematic chart review. SETTING McLean Hospital's geriatric neuropsychiatry unit. PARTICIPANTS Sixteen patients with a diagnosis of dementia treated with ECT for agitation/aggression during 2004-2007. MEASUREMENTS Clinical charts were rated on the Pittsburgh Agitation Scale as the primary outcome, the Clinical Global Impression scale and the Global Assessment of Functioning pre- and post-ECT. RESULTS 16 patients of mean age 66.6 ± 8.3 years were studied. Their average overall and pre-ECT lengths of stay were 59.7 ± 39.7 days and 23 ± 15.7 days, respectively. Patients received a mean of 9 ECT treatments, mostly bilateral. Patients showed significant reductions in their total Pittsburgh Agitation Scale scores from baseline after ECT (from 11.0 ± 5.0 to 3.9 ± 4.3 [F = 30.33, df = 1, 15, p < 0.001]). Clinical Global Impression scale decreased significantly (from 6.0 ± 0.6 pre-ECT to 2.1 ± 1.6 post-ECT [F = 112.97, df = 1, 15, p < 0.001]). Global Assessment of Functioning change was not significant (from 23.0 ± 4.9 to 26.9 ± 6.9 [F = 5.73, df = 1, 13, p = 0.32]). Only one patient, in whom ECT was discontinued following 11 bilateral treatments, showed no improvement. Eight patients showed transient postictal confusion, which typically resolved within 48 hours. Two patients showed more severe postictal confusion that required modification of treatment. CONCLUSIONS These results suggest that ECT is an effective and safe treatment for agitation and aggression in dementia. Further prospective studies are warranted.
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Burgut FT, Popeo D, Kellner CH. ECT for agitation in dementia: Is it appropriate? Med Hypotheses 2010; 75:5-6. [DOI: 10.1016/j.mehy.2010.04.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Accepted: 04/01/2010] [Indexed: 11/28/2022]
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Abstract
Alzheimer's disease (AD) is a complex progressive brain degenerative disorder that has effects on multiple cerebral systems. In addition to cognitive and functional decline, diverse behavioral changes manifest with increasing severity over time, presenting significant management challenges for caregivers and health care professionals. Almost all patients with AD are affected by neuropsychiatric symptoms at some point during their illness; in some cases, symptoms occur prior to diagnosis of the dementia syndrome. Further, behavioral factors have been identified, which may have their origins in particular neurobiological processes, and respond to particular management strategies. Improved clarification of causes, triggers, and presentation of neuropsychiatric symptoms will guide both research and clinical decision-making. Measurement of neuropsychiatric symptoms in AD is most commonly by means of the Neuropsychiatric Inventory; its utility and future development are discussed, as are the limitations and difficulties encountered when quantifying behavioral responses in clinical trials. Evidence from clinical trials of both non-pharmacological and pharmacological treatments, and from neurobiological studies, provides a range of management options that can be tailored to individual needs. We suggest that non-pharmacological interventions (including psychosocial/psychological counseling, interpersonal management and environmental management) should be attempted first, followed by the least harmful medication for the shortest time possible. Pharmacological treatment options, such as antipsychotics, antidepressants, anticonvulsants, cholinesterase inhibitors and memantine, need careful consideration of the benefits and limitations of each drug class.
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Abstract
BACKGROUND Alzheimer disease (AD) patients frequently exhibit agitated behaviors that can be difficult to treat pharmacologically due to side effects and lack of efficacy. Electroconvulsive therapy (ECT) is a potential treatment option for patients who have failed medication trials. METHODS Chart review of agitated AD patients treated at Mayo Clinic with ECT from 2001 to 2006. RESULTS Of 11 patients, 9 had improvement or remission of agitated behavior. Hospitalizations in the year after the initial ECT series decreased significantly for all patients in the study. CONCLUSIONS Electroconvulsive therapy is a safe and effective treatment for agitation in AD patients.
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Wilkins KM, Ostroff R, Tampi RR. Efficacy of electroconvulsive therapy in the treatment of nondepressed psychiatric illness in elderly patients: a review of the literature. J Geriatr Psychiatry Neurol 2008; 21:3-11. [PMID: 18287164 DOI: 10.1177/0891988707311027] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Electroconvulsive therapy (ECT) is well established as a safe and effective treatment for several psychiatric disorders. Responsiveness to ECT does not abate with age, and data indicate that the use of ECT in the treatment of psychiatric disorders in the elderly persons has increased in recent decades. Special consideration must be given to the baseline cognitive abilities of an elderly patient prior to treatment with ECT. Much of the literature on the use of ECT in the elderly persons has focused on the treatment of mood disorders, whereas less research has been devoted to its use in the treatment of other psychiatric conditions. Although depressive syndromes remain the most common indication for ECT in the elderly persons, clinicians treating elderly patients should remain aware of the safety and efficacy of this treatment modality with other psychiatric disorders. This review examines the literature on the use of ECT in elderly patients with some common neuropsychiatric disorders including catatonia, bipolar mania, schizophrenia, dementia with behavioral disturbance, and Parkinson's disease.
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Affiliation(s)
- Kirsten M Wilkins
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA.
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Abstract
We report on the use of electroconvulsive therapy (ECT) in a 20-year-old man with a history of FG syndrome and schizophrenia who demonstrated thought disorder and aggression refractory to pharmacological treatment. He received 71 ECT treatments over a period of 13 months and demonstrated a marked reduction in aggressive behavior. In the 14 months before beginning ECT, the patient spent 189 days in the hospital, whereas in the 13 months subsequent to his initial ECT series as an inpatient, he was able to be maintained in the community without psychiatric hospitalization. This case extends the findings of prior cases documenting the alleviation of aggressive behaviors with ECT.
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Affiliation(s)
- Christopher L Myers
- University of Chicago Pritzker School of Medicine, Chicago, IL 60637-1470, USA
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Abstract
AIM The aim of this paper is to clarify the concept of agitation in dementia through analysing definitions, critical attributes, components, boundaries, antecedents and consequences of agitation. BACKGROUND The concept of agitation is not well defined. In addition, there exists much confusion about the characteristics and boundaries of agitation, as well as the distinction between agitation and related concepts. Recently developed theoretical models for agitation in dementia require new interpretation and conceptualization of agitation. METHODS Morse's method of critical appraisal of the literature was used. In addition, some parts of Rodgers' evolutionary method were employed. Data were selected using six electronic databases and the key words 'agitation', 'agitated', 'dementia', 'demented' and 'Alzheimer'. The analysis included 86 empirical or theoretical papers and one book. RESULTS A transition from the observer's perspective to the patient's perspective in the interpretation of agitation was found. Five critical attributes of agitation in dementia were identified: excessive, inappropriate, repetitive, non-specific and observable. Patient factors, interpersonal factors, environmental factors and restraint were identified as precipitating antecedents. Mediating antecedents included discomfort, unmet need and misinterpretation. Consequences of agitation were identified at the levels of patient, caregiver and others. CONCLUSIONS This transition in perspectives has important implications as it can change health providers' attitudes and responses to agitation and lead to patient-focused and individualized care. Researchers and clinicians are encouraged to avoid labelling agitated behaviour as 'disturbing behaviour'.
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Affiliation(s)
- Eun-Hi Kong
- School of Nursing, University of Pennsylvania, Philadelphia, PA 19104-6106, USA.
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